Digitized  by  the  Internet  Archive 

in  2008  with  funding  from 

IVIicrosoft  Corporation 


http://www.archive.org/details/causesofheartfaiOOroberich 


HARVARD  HEALTH  TALKS 

THE  CARE  OF  CHILDREN 
BY  JOHN  LOVETT  MORSE 

PRESERVATIVES  AND  OTHER 

CHEMICALS  IN  FOODS:  THEIR  USE 

AND  ABUSE 

BY  OTTO  FOLIN 

THE  CARE  OF  THE  SKIN 
BY  CHARLES  JAMES  WHITE 

THE  CARE  OF  THE  SICK  ROOM 
BY  ELBRIDGE  GERRY  CUTLER 

THE  CARE  OF  THE  TEETH 
BY  CHARLES  ALBERT  BRACKETT 

ADENOIDS  AND  TONSILS 
BY  ALGERNON  COOLIDGE 

AN  ADEQUATE  DIET 
BY  PERCY  GOLDTHWAIT  STILES 

HOW  TO  AVOID  INFECTION 
BY  CHARLES  VALUE  CHAPIN 

PNEUMONIA 
BY  FREDERICK  TAYLOR  LORD 

NEW  GROWTHS  AND  CANCER 
BY  SIMEON  BURT  WOLBACH 

THE  CAUSES  OF  HEART  FAILURE 
BY  WILLIAM   HENRY  ROBEY 


HARVARD  HEALTH  TALKS 


HARVAED  HEAL'te'tALK^  ••••''•' 

THE  CAUSES  OF  HEART 
FAILURE 

BY 

WILLIAM  HENRY  ROBEY 

ASSISTANT  PB0FES80B  OP  MEDICINE  IN  HABVABD  UNIVEBSITT 
VISITING  PHYSICIAN  TO  THE  BOSTON  CITY  HOSPITAL 


^ 


CAMBRIDGE 
HARVARD  UNFS^ERSITY  PRESS 

LONDON:  HTJMPHBEY  MILFORD 
OXrOBD  UNIYKBaiTY  PBSBS 

19^^ 


^^" 


.^^^ 


COPYRIGHT,  1922 
HABVABD  tJNIVERSITT  PRESS 


HARVARD  HEALTH  TALKS 

PRESENTING  the  substance  of  some 
-*•  of  the  public  lectures  delivered  at 
the  Medical  School  of  Harvard  Univer- 
sity, this  series  aims  to  provide  in  easily 
accessible  form  modern  and  authorita- 
tive information  on  medical  subjects 
of  general  importance.  The  following 
committee,  composed  of  members  of 
the  Faculty  of  Medicine,  has  editorial 
supervision  of  the  volumes  published: 

EDWARD  HICKLING  BRADFORD, 
A.M.,  M.D.,  Dean  of  the  Faculty  of 
Medicine,  and  Professor  of  Orthopedic 
Surgery,  Emeritus. 

HAROLD  CLARENCE  ERNST,  A.M., 
M.D.,  Professor  of  Bacteriology. 

WALTER  BRADFORD  CANNON,  A.M., 
M.D.,  George  Higginson  Professor  of 
Physiology. 


4H0i!? 


THE  CAUSES  OF  HEART 
FAILURE 


THE    CAUSES   OF  HEART 
FAILURE 

SEVERAL  years  ago  newspapers 
throughout  the  country  amused 
themselves  with  jests  about  deaths  from 
heart  failure.  They  were  not  untimely, 
for  it  was  obvious  to  the  layman  that  in 
the  last  analysis  the  patient  had  died  of 
heart  failure.  It  was  clear  that  if  a  man's 
heart  stopped  beating  his  life  would 
cease,  no  matter  what  the  underlying 
cause  might  be.  It  is,  and  always  has 
been,  quite  unscientific  for  physicians  to 
give  "heart  failure"  as  a  cause  of  death. 
Many  years  ago  registrars  refused  to  ac- 
cept from  physicians  a  death  certificate 
in  which  "heart  failure  "  was  given  as  the 
cause.  In  1910  the  Federal  Government 
issued  the  Physicians'  Pocket  Reference  to 
the  International  List  of  Causes  of  Deaths 
on  the  flyleaf  of  which  was  the  following 


HARVARD  HEALTH  TALKS 

quotation  from  Dr.  Charles  V.  Chapin, 
superintendent  of  health  in  Providence, 
Rhode  Island:  ''The  registration  of  vital 
statistics  is  the  firm  basis  on  which  the 
whole  structure  of  sanitary  science  and 
practice  must  rest.  In  order  to  learn 
the  laws  of  disease,  to  devise  remedies 
and  test  them,  we  must  have  approxi- 
mately accurate  knowledge  of  the  move- 
ment of  population  and  of  the  causes  of 
death."  In  signing  a  death  certificate  the 
best  trained  physicians  have  not  within 
the  lifetime  of  many  of  us  given  such  a 
meaningless  cause.  Notwithstanding  all 
this,  the  term  "heart  failure"  has  re- 
mained in  medical  parlance  where  it  has 
a  perfectly  good  place  if  its  significance 
is  understood.  To  the  mind  of  the  intelli- 
gent physician  the  expression  "heart 
failure"  never  means  the  death  of  the 
heart  —  that  is  too  obvious.  It  means 
that  the  heart  is  failing  to  do  its  work 
and  that  brings  us  to  the  consideration 
of  our  subject  —  the  causes  which  make 

10 


CAUSES  OF  HEART  FAILURE 

the  heart  fail.  That  is  what  Dr.  Chapin 
meant  when  he  said  that  in  order  to  learn 
the  laws  of  disease  and  to  devise  remedies 
we  must  have  an  approximately  accurate 
knowledge  of  the  causes  of  disease.  If  we 
are  to  prevent  heart  disease  we  must  be 
alive  to  its  causes  and  so  greatly  lessen 
the  affections  of  this  vital  organ. 

Structure  and  Mechanism 
OF  THE  Heart 

Let  us  look  for  a  moment  at  the  heart 
and  consider  its  structure  and  work.  It  is 
a  somewhat  conical  body  placed  in  the 
anterior  portion  of  the  thorax  behind  the 
sternum  or  breast  bo;ne,  lying  almost  in 
the  median  line,  rather  more  to  the  left 
than  the  right.  Its  apex  hangs  down- 
ward and  backward  and  rests  upon  the 
diaphragm,  the  large  muscular  division 
which  separates  the  thoracic  from  the 
abdominal  cavity.  Its  base  is  at  the 
third  rib  where  it  is  held  firmly  in  place 
and  where  the  great  veins  enter  and  the 

11 


HARVARD  HEALTH  TALKS 

aorta  is  given  ojff.  The  heart  may  be  said 
to  be  in  two  main  divisions  which  we 
speak  of  for  convenience  as  the  right  and 
left  heart.  Each  side  is  again  divided 
into  two  parts,  the  auricle  and  ventricle. 
The  right  auricle  receives  the  blood  from 
the  great  veins,  passes  it  through  the 
right  auricular-ventricular  opening  into 
the  right  ventricle  from  which  its  back- 
ward flow  is  prevented  by  the  tricuspid 
valve.  The  right  ventricle  contracts  and 
drives  the  blood  through  the  pulmonary 
artery  into  the  lungs  and  thence  through 
the  pulmonary  veins  into  the  left  auricle 
from  which  it  passes  through  the  left 
auricular-ventricular  opening  into  the 
left  ventricle.  When  the  left  ventricle 
contracts,  the  blood  is  forced  into  the 
aorta  and  thence  through  the  body.  Its 
backward  flow  into  the  auricle,  when 
the  ventricle  contracts,  is  prevented  by 
the  closure  of  the  mitral  valve.  After 
the  blood  has  entered  the  aorta,  it  is 
prevented  from  returning  to  the  left  ven- 

10 


CAUSES  OF  HEART  FAILURE 

tricle  by  the  immediate  closure  of  the 
aortic  valves.  This  wonderfully  adjusted 
piece  of  mechanism  works  in  health  with 
perfect  regularity,  the  auricles  contract- 
ing on  the  average  72  times  per  minute  to 
be  immediately  followed  by  72  contrac- 
tions of  the  ventricles.  Each  auricular 
contraction  is  followed  by  a  ventricular 
contraction  in  rhythmic  sequence.  The  ^ 
heart  is  a  muscular  organ  and  the  thick- 
ness and  strength  of  the  walls  of  its 
chambers  vary  with  the  work  required  of 
them.  Because  it  takes  much  more  force 
to  drive  the  blood  through  the  body  than 
through  the  lungs,  the  thickness  and 
strength  of  the  left  ventricular  wall  is 
about  four  times  greater  than  the  right. 
Since  it  is  a  muscle,  it  must,  like  all  other 
muscles,  be  nourished  with  blood  and 
this  is  accomplished  by  the  coronary  or 
crown  artery  which  is  given  off  from  the 
aorta  and  divides  into  two  branches,  one 
to  the  right  and  the  other  to  the  left.  The 
two  main  branches  again  divide  into 

13 


HARVARD  HEALTH  TALKS 

many  smaller  branches,  the  whole  struc- 
ture resembling  a  great  tree.  The  heart 
is  enclosed  in  a  serous  sack,  the  pericar- 
dium, the  surfaces  of  which  lie  in  appo- 
sition with  about  an  ounce  and  a  half  of 
serum  quite  evenly  distributed  between 
the  surfaces  to  act  as  a  lubricant.  All  of 
the  structures  of  the  heart  may  be  the 
seat  of  disease,  singly  or  in  varying  com- 
binations, the  muscle  {myocarditis),  the 
valve  and  valve  openings  {endocarditis) , 
the  pericardium  {pericarditis)  and  the  cor- 
onary arteries  {coronary  disease;  arterio- 
sclerosis). 

The  heart  muscle  supplies  the  force 
which  maintains  the  flow  of  blood 
through  the  lungs  and  through  the  body. 
In  the  normal  circulatory  mechanism  all 
parts  are  so  adjusted  that  the  work  of  the 
heart  is  facilitated  and  any  disturbance 
in  any  part  of  the  heart  or  in  other  or- 
gans increases  the  work  of  efficiently 
maintaining  the  circulation  and  eventu- 
ally leads  to  overwork  and  failure  of  the 

14 


CAUSES  OF  HEART  FAILURE 

heart.  So  long  as  the  heart  can  over- 
come the  effects  of  disease  and  maintain 
the  circulation  normally  no  symptoms 
are  evoked,  but  when  too  great  a  strain 
is  put  upon  it  signs  of  fatigue  and  failure 
appear.  No  matter  what  the  cause,  the 
result  is  always  embarrassment  and  fi- 
nally exhaustion  of  the  heart. 

The  Commonest  Forms  of  Heart 
Disease 

1.   The  Arteriosclerotic  Heart 

The  arterio-sclerotic  heart  is  some- 
times spoken  of  as  the  ''old-age  heart." 
With  hardening  of  the  arteries  through- 
out the  body,  the  coronary  arteries  gen- 
erally become  involved,  the  circulation 
of  the  heart  is  impeded  and  the  muscle 
undernourished.  The  person  becomes 
breathless  with  any  slight  exertion,  fa- 
tigues easily  and  may  have  pain  in  the 
region  of  the  heart  or  a  sensation  of  pres- 
sure about  the  root  of  the  neck  as  though 

15 


HARVARD  HEALTH  TALKS 

the  throat  was  compressed.  The  pain 
may  shoot  down  the  arm  into  the  fingers 
or  there  may  be  tender  points  on  pres- 
sure over  the  heart  area.  The  occlusion 
of  a  large  branch  of  the  coronary  artery 
is  a  frequent  cause  of  sudden  death  in  an 
ojd  person.  An  old  gentleman  who  had 
always  been  vigorous  noticed  that  he  be- 
came breathless  with  exertion  and  often 
had  attacks  of  acute  indigestion.  He  was 
treated  by  a  physician  for  "stomach 
trouble"  without  relief.  Upon  examina- 
tion evidences  of  a  moderate  degree  of 
arterio-sclerosis  were  found  with  some 
increase  in  blood  pressure.  By  limiting 
his  activities  and  requiring  him  to  take 
frequent  rest  periods  his  indigestion 
ceased  and  he  felt  as  well  as  before.  As 
chaplain  of  a  Grand  Army  Post,  he  was 
impelled  to  conduct  the  funeral  services 
of  a  comrade  but  the  effort  was  too 
great,  he  collapsed  and  was  carried  home. 
A  few  days  of  rest  made  him  feel  as  well 
as  ever  and  he  was  advised  to  avoid  emo- 

16 


CAUSES  OF  HEART  FAILURE 

tional  as  well  as  physical  strain.  Some 
two  weeks  later  he  became  involved  in  an 
altercation  with  a  man  on  his  place,  fell 
to  the  ground  and  died  before  the  phy- 
sician who  was  summoned  could  reach 
him.  It  should  be  remembered  that 
emotional  strain  is  often  as  great  a  factor 
in  overtaxing  the  heart  as  physical  work. 
The  physician  realizes  this  when  he  treats 
the  overworried  business  man  with  an- 
gina pectoris. 

The  physician  may  be  misled  by  the 
absence  of  any  marked  abnormal  signs 
in  the  heart  and  circulation  of  a  middle- 
aged  or  elderly  individual.  There  will, 
however,  usually  be  some  found  if  the 
search  is  thorough.  The  history  is  of 
great  importance. 

Pain  about  the  heart  in  the  elderly 
should  always  be  taken  seriously  and 
the  patient's  response  to  effort  carefully 
studied.  Persons  of  all  ages  may  have 
pain  which  may  or  may  not  be  due 
to  cardiac  disease.    Children  sometimes 

17 


HARVARD  HEALTH  TALKS 

suffer  from  pain  in  the  cardiac  area 
caused  by  overeating,  indigestion  or  con- 
stipation. It  may  be  due  to  valvular 
disease  of  the  heart,  such  as  mitral  ste- 
nosis or  aortic  regurgitation.  In  the  first 
instance  a  correction  of  the  digestion  and 
habits  of  eating  will  remove  the  symp- 
tom, while  in  the  latter  the  physician 
recognizes  it  as  one  of  the  signs  of  struc- 
tural damage  resulting  from  some  infec- 
tious disease.  Certain  nervous  condi- 
tions such  as  neurocirculatory  asthenia 
(effort  syndrome;  soldier's  heart)  cause 
heart  pain.  In  this  condition  there  is  no 
organic  disease  of  the  heart.  The  exces- 
sive use  of  tobacco  is  another  cause  of 
pain  known  as  "tobacco  angina."  Why 
it  occurs  in  one  person  and  not  in  an- 
other is  unknown  unless  the  theory  that 
it  attacks  those  with  some  underlying  or- 
ganic basis  be  tenable.  Usually  the  ces- 
sation of  tobacco  for  a  few  weeks  will 
remove  the  pain. 


18 


CAUSES  OF  HEART  FAILURE 

Breathlessness  coming  on  with  any 
slight  exertion  is  very  important,  espe- 
cially if  it  occurs  when  the  individual  is 
sitting  quietly  or  is  awakened  at  night 
with  a  smothering  sensation. 

Fatigue  in  a  person  who  states  that  his 
usual  walk  can  no  longer  be  taken  with- 
out undue  weariness  should  not  be  over- 
looked. 

We  do  not  ask  the  physician  to  take 
towards  his  patient  the  attitude  of  the 
illiterate  police  magistrate  who  summed 
up  each  case  in  this  wise:  "When  I  look 
at  the  prisoner  in  the  dock,  I  says  to  my- 
self, well,  if  he  hadn't  done  something  he 
wouldn't  be  there,  so  I  finds  him  guilty," 
— but  we  do  ask  the  physician  to  weigh 
the  evidence  carefully  before  beginning 
treatment.  He  must  answer  the  ques- 
tion—  can  the  patient  "carry  on"  .^ 
Let  me  give  two  examples  of  what  we 
mean  by  failure  to  "carry  on."  A  pa- 
tient, for  thirty  years  a  railroad  engi- 


19 


HARVARD  HEALTH  TALKS 

neer,  was  accused  by  the  legal  depart- 
ment of  sleeping  in  his  cab  between  sta- 
tions. He  was  taken  from  his  engine 
immediately  to  the  office  of  the  medical 
examiner  who  found  a  very  high  blood 
pressure  but  practically  no  other  signs. 
In  three  days  of  rest  his  pressure  dropped 
to  normal  and  in  two  or  three  weeks  he 
was  allowed  to  resume  work  but  with  the 
same  result.  Another  and  longer  rest 
period  was  taken  and  he  was  then  given 
a  freight  engine,  possibly  with  the  idea 
of  greater  safety,  but  all  to  no  purpose. 
The  man  was  highly  indignant  when  de- 
moted to  a  yard  job,  but  three  months 
later  when  entering  the  yard  gate  he  fell 
dead.  The  heart  and  circulation  could 
no  longer  stand  the  nervous  strain  of  en- 
gine driving.  Fortunately,  the  regular 
examination  of  engineers  greatly  elim- 
inates this  danger.  A  well  nourished 
middle-aged  business  man  had  carried 
out  the  same  routine  for  nearly  thirty 
years.    Every  morning  he  walked  about 

20 


CAUSES  OF  HEART  FAILURE 

two  blocks  up  an  incline  to  the  street- 
car, but  for  two  years  had  noticed  that 
he  could  not  do  it  without  breathless- 
ness.  One  morning  he  ran  for  his  car, 
collapsed  and  was  in  his  bed  when  he 
recovered  consciousness.  His  physician 
could  find  very  few  signs  of  heart  dis- 
ease, but  because  of  his  history  had 
urged  a  change  in  his  mode  of  life.  The 
patient  absolutely  refused  to  heed  the 
warning  and  two  weeks  later  had  an- 
other collapse  in  which  he  died.  This 
was  the  result  of  undue  physical  strain 
on  a  damaged  heart. 

2.    The  Rheumatic  Heart 

The  rheumatic  heart  includes  damage 
by  rheumatic  fever,  chorea,  tonsillitis, 
and  scarlet  fever.  These  diseases  have 
the  power  of  attacking  all  or  any  one  of 
the  structures  of  the  heart.  It  is  impor- 
tant for  the  physician  to  inspect  the 
heart  carefully  during  the  course  of  the 
disease  to  discover  the  onset  of  lesions 

21 


HARVARD  HEALTH  TALKS 

which  will  later,  if  not  guarded  against, 
cause  impairment.  After  an  acute  infec- 
tion has  ceased,  it  is  necessary  for  the 
patient  to  be  seen  at  regular  intervals 
because  there  are  some  lesions  which  do 
not  appear  immediately.  The  heart  may 
seem  to  be  normal  for  a  time,  but  later 
the  evidence  of  damage  presents  itself. 
This  is  particularly  true  of  the  condi- 
tion known  as  mitral  stenosis  —  one  of 
the  greatest  dangers  of  acute  rheumatic 
fever  in  young  people.  Chorea  or  Saint 
Vitus  Dance  has  often  been  classed  and 
treated  as  an  entity,  but  is,  in  the  opin- 
ion of  some  of  us,  merely  a  part  of  the 
symptom  complex  of  acute  rheumatism. 
When  present,  even  if  unaccompanied  by 
other  signs,  it  should  not  be  dismissed 
without  a  thorough  sea^rch  for  foci  of 
infection. 

Since  acute  articular  rheumatism  (rheu- 
matic fever)  often  causes  heart  disease 
and  tonsillitis  is  frequently  followed  by 
rheumatism  and  cardiac  disease,  the  im- 

22 


CAUSES  OF  HEART  FAILURE 

portance  of  removing  diseased  tonsils  is 
evident.  Not  every  person  with  enlarged 
tonsils  requires  tonsillectomy  (removal 
by  operation), but  an  operation  should  be 
performed  if  there  are  repeated  attacks. 
Persons  with  rheumatism  or  rheumatic 
heart  disease  should  have  their  tonsils 
thoroughly  inspected  by  a  competent 
laryngologist.  In  this  way  only  can  re- 
currences be  prevented,  the  heart  saved 
or  additional  damage  avoided.  The  small 
"buried"  tonsil  is  often  more  danger- 
ous than  the  large  one.  Recently  a  new 
method  of  destroying  the  lymphoid  tissue 
of  the  tonsil  by  the  application  of  radium 
or  the  X-ray  has  come  into  use.  The 
shrinking  of  the  tonsil  is  quite  marvelous 
even  with  one  treatment,  but  time  alone 
wfU  prove  the  value  of  the  procedure. 
Unless  the  method  absolutely  prevents 
re-infection  it  is  useless  and  waiting  is 
sometimes  very  dangerous. 

Dr.  Alexander  Lambert  of  New  York 
states  that  the  number  of  cases  of  acute 

23 


HARVARD  HEALTH  TALKS 

rheumatism  in  the  Bellevue  Hospital  has 
diminished  in  recent  years  and  attributes 
this  improvement  to  the  care  of  the  noses, 
throats,  and  teeth  of  the  school  chil- 
dren. In  Boston,  acute  rheumatism  is 
not  the  common  disease  it  was  twenty- 
five  years  ago. 

Potential  Heart  Disease 

Potential  Heart  Disease  is  a  term 
which  has  been  used  recently  and  means 
that  a  person  who  has  recurrences  of  any 
infection  (tonsils,  teeth,  sore  throats, 
rheumatism,  etc.)  is  in  danger  of  cardiac 
involvement.  His  heart  may  escape 
during  the  first  and  second  infections, 
but  with  the  third  it  may  be  involved. 
Hence  the  importance  of  removing  the 
sources  of  danger  before  it  is  too  late. 
A  young  girl  has  had  two  rather  severe 
attacks  of  tonsillitis  and  as  far  as  we  can 
see  the  heart  has  not  been  affected.  We 
have  strongly  urged  the  removal  of  the 
tonsils,  but  operation  has  been  refused. 

24 


CAUSES  OF  HEART  FAILURE 

At  any  time  a  third  attack  may  come 
and  if  heart  disease  should  result  we 
would  all  be  regretful,  but  it  would  then 
be  too  late. 

Pericarditis 

Sometimes  only  the  valves  are  af- 
fected, but  often  the  valves,  muscle,  and 
pericardial  sack  are  involved  giving  what 
is  called  a  pancarditis.  The  recognition 
by  the  physician  of  the  appearance  of 
pericarditis  during  the  course  of  an  acute 
infection  is  of  great  importance,  since  it 
may  be  the  only  evidence  at  the  time  of 
a  pancarditis  and  may  warn  the  phy- 
sician to  search  for  other  lesions  then 
and  later. 

3.    The  Syphilitic  Heart 

The  late  Sir  WiUiam  Osier  said,  ''It 
is  to  be  remembered  that  syphilis  is 
common  in  the  community  and  there 
are  probably  more  families  with  a 
luetic  than  a  tubercular  taint."    This 

25 


HARVARD  HEALTH  TALKS 

is  a  sad  commentary  knowing  as  we 
do  that  syphilis  is  a  preventable  dis- 
ease. Its  effect  upon  the  heart  may  be 
acute  or  chronic  and  its  progress  insidi- 
ous. The  parasite  of  syphilis  attacks 
the  heart  muscle  and  more  particularly 
the  aorta  and  aortic  valve.  Regurgi- 
tation of  blood  through  the  aortic  valve 
in  a  child  is  often  the  result  of  rheumatic 
infection,  but  in  a  middle-aged  man  it 
is  frequently  due  to  syphilis.  Ten  to 
twenty  years  after  the  initial  lesion  the 
syphilitic  heart  gives  its  first  sign  of 
distress,  incapacitates  the  sufferer,  and 
closes  a  life  which  should  halve  seen 
twenty  to  thirty  years  more  of  useful- 
ness. Much  has  been  done  to  prevent 
syphilitic  cardiac  disease  by  early  diag- 
nosis of  the  initial  lesion  and  prompt, 
thorough,  and  repeated  treatments  but, 
notwithstanding,  some  do  not  escape. 
Is  it  any  wonder  that  the  United  States 
Public  Health  Service  and  other  organi- 
zations are  doing  all  in  their  power  to 

26 


CAUSES  OP  HEART  FAILURE 

stamp  but  this  menace  by  various  educa- 
tional methods  ? 

Jf..   Other  Infections 

Pneumonia,  typhoid  fever,  tubercu- 
losis and  certain  obscure  infections  affect 
the  cardiac  structures,  but  this  is  chiefly 
a  medical  problem  of  interest  during  and 
immediately  after  the  course  of  the  dis- 
ease. 

5.  Nervous  Influences 

Certain  nervous  disorders  increase  the 
cardiac  rate  as  hyperthyroidism  (goitre) 
and  neurocirculatory  asthenia  (soldier's 
heart).  This  becomes  important  when 
the  condition  persists  for  a  considerable 
period  of  time  by  fatiguing  the  over- 
worked heart  muscle. 

6.  Blood  Pressure 

Any  condition  which  produces  a  con- 
stantly high  blood  pressure  as  in  kidney 
disease  or  arterio-sclerosis. 

27 


HAHVARD  HEALTH  TALKS 

7.    The  Athlete's  Heart 

We  are  often  asked  by  anxious  parents 
if  school  and  college  games  injure  the 
heart.  The  experience  of  those  who  have 
seen  large  numbers  of  college  athletes 
is  that  even  strenuous  exercise  rarely 
injures  the  heart,  provided  the  athlete 
begins  with  a  normal  heart  and  is  grad- 
ually trained.  The  collapse  at  the  end 
of  a  contest  is  more  often  nervous  than 
muscular. 

Irregularities  of  Heart  Action 

Children  often  have  normally  an  ir- 
regular action  of  the  heart  known  as 
**  sinus  arrhythmia."  It  will  be  noticed 
when  the  child  breathes  deeply  or  cries 
that  the  pulse  becomes  irregular  yet  he 
can  play  without  undue  fatigue.  There 
is  no  lack  of  cardiac  response  to  ef- 
fort. All  other  irregularities  have,  with 
certain  exceptions,  some  pathological 
significance  and  should  be  thoroughly 

28 


CAUSES  OF  HEART  FAILURE 

investigated.  Extra  beats  of  the  heart 
may  occur  at  all  ages  and  are  not  always 
important  if  inconstant.  In  old  persons 
in  apparently  good  health  they  are  quite 
common. 

Prevalence  of  Heart  Disease 

Heart  disease  has  become  a  greater 
cause  of  death  than  tuberculosis.  In 
New  York  for  ten  years  it  has  been  re- 
sponsible for  200  deaths  in  every  100,Q00 
of  the  population,  while  in  1920  tubercu- 
losis caused  126  deaths  in  every  100,000. 
In  1919  the  death  rate  from  organic  heart 
disease  was  181  per  100,000  of  the  popu- 
lation of  Massachusetts. 

It  is  not  a  rapidly  fatal  condition  as 
many  people  suppose,  but  one  which 
usually  means  years  of  suffering  and  dis- 
ability. Most  of  the  sudden  deaths  occur 
in  old  i>eople.  Even  when  the  end  is  un- 
expected, premonitory  signs  have  fre- 
quently been  present  waiting  for  recog- 
nition.  The  economic  waste  from  heart 

29 


HARVARD  HEALTH  TALKS 

disease  in  the  United  States  is  tremen- 
dous and  therefore  the  great  problem  of 
prevention,  early  diagnosis,  and  relief 
appeals  not  only  to  physicians  but  to  the 
general  public.  The  crusade  which  has 
been  going  on  for  years  against  tuber- 
culosis by  various  organizations,  the  in- 
struction of  patients  in  sanatoria  and 
the  appreciation  of  early  diagnosis  and 
proper  protection  against  infection  by 
physicians  has  made  the  disease  so  fa- 
miliar to  the  country  at  large  that  the 
dreaded  '* Great  White  Plague"  has 
steadily  diminished.  When  the  public 
realizes  that  [heart  disease  is  prevent- 
able by  early  recognition  of  its  causes, 
a  great  step  will  have  been  taken  in  ad- 
vance. The  stress  of  modern  life  will 
continue  to  tax  the  circulatory  system 
and  old  age  will  probably  close  in  many 
instances  with  coronary  disease,  but  this 
result  can  be  greatly  delayed  by  proper 
living  and  freedom  from  infectious  dis- 
eases in  early  life.   Our  greatest  hope  is 

so 


CAUSES  OF  HEART  FAILURE 

for  the  children.  Much  has  been  written 
about  treatment  but  more  must  be  said 
and  written  about  prevention.  One  of 
the  largest  fields  today  for  preventive 
medicine  is  the  instruction  of  the  public 
in  the  importance  of  thoroughly  under- 
standing the  causes  of  infections  which 
involve  the  heart.  For  this  purpose  sev- 
eral large  cities  now  have  associations  of 
physicians  and  laymen.  Their  meetings 
are  open  to  all  interested  people  and  their 
transactions  are  reported  in  the  daily 
press.  In  Boston  there  is  the  Association 
of  Cardiac  Clinics  which  holds  meetings 
four  times  a  year.  The  public  schools 
have  the  throats  and  teeth  of  their  pupils 
inspected.  There  is  now  an  organized 
movement  to  carry  instruction  to  all  parts 
of  the  country. 

Diagnosis 

The  diagnosis  of  heart  disease  can  be 
made  only  after  all  methods  of  examina- 
tion have  been  employed.  The  examina- 

81  f 


HARVARD  HEALTH  TALKS 

tion  must  be  thorough  and  frequently  re- 
peated. The  stethoscope,  X-ray,  blood 
pressure  apparatus,  polygraph,  and  elec- 
trocardiograph all  contribute  findings  of 
varying  importance  in  arriving  at  a  final 
interpretation  of  the  physical  signs.  No 
instrument  of  precision  will  give  all  the 
necessary  information.  A  normal  elec- 
trocardiogram, for  example,  would  not 
convince  the  experienced  physician  of 
the  absence  of  disease  if  other  striking 
physical  signs  were  present.  In  old  peo- 
ple there  may  be  very  few  objective 
symptoms  but  a  history  of  pain,  breath- 
lessness,  and  undue  fatigue  will  often  aid 
in  diagnosis. 

Some  years  ago  a  great  deal  of  atten- 
tion was  paid  to  heart  murmurs,  but  later 
it  was  found  that  to  be  significant  they 
must  be  associated  with  other  physical 
findings.  Children  sometimes  had  mur- 
murs which  were  unimportant,  but  as 
Sir  James  Mackenzie  pointed  out  several 
years  ago  their  activities  were  needlessly 

82 


CAUSES  OP  HEART  FAILURE 

limited.  A  career  has  been  ruined  be- 
cause too  much  has  been  made  of  a  mean- 
ingless murmur.  A  healthy  child  who 
can  play  as  hard  as  his  fellows  without 
abnormal  fatigue  may  generally  have 
his  murmur  disregarded  if  other  physi- 
cal signs  are  absent.  We  have  all  seen 
people  who  have  gone  about  for  years  in 
fear  because  at  some  period  in  their  lives 
a  murmur  had  been  discovered.  So  the 
physician  must  be  able  to  distinguish  be- 
tween functional  and  organic  heart  dis- 
ease. Some  forms  of  heart  affections,  as 
regurgitation  at  the  aortic  valve,  may 
exist  for  years  without  giving  subjective 
symptoms.  Near  the  close  of  the  World 
War  the  British  Medical  Journal  reported 
the  case  of  a  captain  of  infantry  who  had 
seen  active  service  at  the  front  for  three 
and  a  half  years  and  was,  in  addition,  the 
director  of  athletics  in  his  area.  This  offi- 
cer carried  on  during  all  that  time  with 
aortic  regurgitation  which  was  not  dis- 
covered until  his  heart  failed  suddenly 

33 


HARVARD  HEALTH  TALKS 

and  he  was  sent  to  the  rear.  Probably 
in  the  haste  of  mobilization  his  lesion 
was  overlooked  by  the  examining  board. 

Treatment 

It  is  clear  that  prophylaxis  and  the 
recognition  of  potential  heart  disease 
come  first  by  the  removal  of  foci  of  infec- 
tion such  as  diseased  tonsils,  the  care 
and  possible  extraction  of  carious  teeth, 
the  X-ray  examination  by  an  exj>ert  of 
the  teeth  in  doubtful  cases  especially  the 
sealed  or  crowned  tooth,  the  prevention 
of  acute  rheumatism  and  thorough  pro- 
tection against  infectious  diseases,  the 
establishment  of  a  proper  diet  with  good 
digestion,  and  the  best  hygienic  meas- 
ures. While  of  the  utmost  importance 
in  prevention  their  danger  is  not  les- 
sened by  the  detection  of  a  heart  lesion, 
because  foci  of  infection  if  allowed  to 
continue  add  to  the  damage.  The  prev- 
alence of  syphilis  should  be  borne  in 
mind  and  its  detection  in  adults  should 

34 


CAUSES  OF  HEART  FAILURE 

be  made  by  the  Wassermann  test.  The 
recognition  of  unsusj>ected  syphiKs  may 
save  a  man  from  its  serious  cardiac  se- 
quelae in  after  years.  Thorough  routine 
physical  examinations  of  apparently 
healthy  people  should  be  made  at  rea- 
sonable intervals.  In  this  way  latent 
causes  and  early  circulatory  diseases  will 
be  detected.  We  have  our  watches  and 
automobiles  regularly  overhauled,  but 
we  allow  our  bodies  to  go  until  they 
break.  The  dentists  have  outstripped 
the  physicians  in  this  respect  by  insisting 
on  regular  inspection  of  the  teeth.  The 
dental  patient  receives  notice  of  an  ap- 
pointment twice  a  year  which  he  keeps 
knowing  that  the  early  recognition  of 
decay  will  save  his  teeth,  health,  and 
mqney.  Why  do  not  all  physicians  have 
such  an  arrangement  with  their  regular 
patients?  Fortunately,  the  public  is 
learning  the  importance  of  these  pre- 
cautionary examinations  and  is  more 
and  more  demanding  them.    Some  per- 

35 


HARVARD  HEALTH  TALKS 

sons  derive  great  comfort  by  belonging 
to  companies  which  examine  the  urine 
at  stated  intervals.  Such  an  examina- 
tion may  or  may  not  reveal  the  presence 
of  kidney  disease;  it  will  very  rarely  dis- 
close a  damaged  heart.  An  examination 
of  the  heart,  however,  will,  if  such  exist, 
reveal  cardiac  abnormalities  and  may  in- 
dicate the  possibility  of  kidney  involve- 
ment. An  intelligent  business  man  once 
told  me  with  a  good  deal  of  satisfaction 
that  he  sent  his  urine  twice  a  year  to 
a  laboratory  and  received  reports  for 
which  he  paid  ten  dollars.  A  young 
colleague  thought  well  of  the  idea  and 
they  formed  the  plan  of  combining  their 
urines  in  the  same  container  and,  inci- 
dentally, sharing  the  expense.  When  I 
asked  him  what  he  would  do  in  the  case 
of  a  positive  finding,  he  blandly  replied 
that  each  would  seek  his  own  physician 
to  discover  the  source.  Nothing  can 
replace  the  complete  physical  examina- 
tion.  Recently  the  medical  director  of  a 

so 


CAUSES  OF  HEART  FAILURE 

large  insurance  company  informed  me 
that  80  per  cent  of  the  rejected  appli- 
cants have  the  causes  of  rejection  dis- 
covered first  by  the  medical  examiner 
and  not  by  their  physicians  as  should  be 
the  case. 

We  have  shown  quite  conclusively 
that  the  best  method  of  treatment  is  to 
remove  the  cause  of  heart  infection  in 
the  young  and  to  delay  circulatory  de- 
generation in  the  old,  but  if  disease  is 
detected  the  medical  treatment  varies 
with  the  cause  and  degree  of  involve- 
ment. 

Rest  is  the  most  important  agent  in 
the  care  of  all  forms  of  heart  disease 
and  satisfying  sleep  must  be  secured.  In 
acute  heart  disease  absolute  rest  in  bed 
is  imperative  during  and  for  a  consider- 
able period  after  the  attack.  Children 
are  frequently  kept  in  bed  for  weeks 
and  months  until  the  infection  has  com- 
pletely subsided  and  the  heart  muscle 
has  recovered  its  power.    In  the  acute 

87 


HARVARD  HEALTH  TALKS 

stage  the  patient  should  not  be  allowed 
to  make  any  exertion  and  should  be 
assisted  even  when  turning  in  bed. 
Straining  at  stool  should  be  avoided  by 
the  use  of  suitable  cathartics.  The  diet 
should  be  light  and  easily  digestible.  In 
the  febrile  stage  the  farinaceous  diet  is 
best.  Enough  water  should  be  given  to 
relieve  thirst  and  insure  a  reasonable 
urinary  output.  An  icebag  over  the 
precordia,  while  it  probably  has  no  effect 
upon  the  disease,  often  gives  comfort. 
It  should  be  very  light  otherwise  a  bur- 
den is  added  to  a  laboring  chest.  The 
patient  is  assisted  in  breathing  by  re- 
clining upon  several  pillows. 

Drugs  in  the  acute  stage  are  indicated 
by  the  character  of  the  infection.  Sleep 
may  be  secured  by  various  hypnotics 
such  as  the  bromides  and  veronal.  Co- 
deine and  morphia  are  perhaps  the  best 
for  quieting  the  heart  and  giving  sleep  in 
the  more  severe  cases. 


88 


CAUSES  OF  HEART  FAILURE 

Chronic  Heart  Disease 

Certain  forms  and  conditions  of  chronic 
heart  disease  do  not  require  medication 
but  merely  a  sensible  direction  of  the 
patient's  life.  All  sources  of  possible 
local  infection  should  be  treated  such  as 
diseased  tonsils,  adenoids,  pyorrhea,  and 
infected  teeth.  Discretion  must  be  used, 
however,  in  estimating  the  importance  of 
these  conditions.  Cardiac  patients  must 
be  careful  about  head  colds  and  attacks 
of  bronchitis,  and  such  intercurrent  af- 
fections should  be  treated  with  dispatch 
and  thoroughness  since  they  tend  to 
throw  added  work  on  the  heart. 

If  the  physician  has  assured  himself 
that  the  patient  has  organic  heart  dis- 
ease he  should  secure  his  cooperation  by 
a  simple  and  tactful  explanation  of  the 
true  nature  of  the  condition.  The  pa- 
tient may  be  temporarily  disturbed  by 
the  information,  but  he  will  quickly  ad- 


39 


HARVARD  HEALTH  TALKS 

just  himself  to  it  and  will  thereby  add 
greatly  to  his  life  and  comfort. 

Exercise.  Muscular  work  increases  the 
heart  rate  and  raises  the  blood  pres- 
sure, but  it  also  improves  the  circula- 
tion. Moderate  physical  exercise  gives  a 
greater  supply  of  fresh  air,  increases  the 
pulmonary  expansion,  benefits  the  diges- 
tion, and  causes  a  healthier  action  of  the 
skin,  thereby  improving  the  circulation 
and  the  general  health.  It  is  diflScult  to 
control  the  activity  of  children,  but  by 
watching  the  effect  of  reasonable  exer- 
cise and  not  exaggerating  the  dangers  of 
occasional  excesses  they  will  be  in  better 
condition  physically  than  those  who  be- 
come nervous  and  apprehensive  by  con- 
stant repression.  Games  which  require 
hard  physical  work  should  not  be  al- 
lowed. 

In  adult  life  the  same  rules  obtain. 
Walking,  riding,  and  light  games  may 
all  be  indulged  in  provided  they  do  not 
produce  the  signs  of  cardiac  overwork. 

40 


CAUSES  OF  HEART  FAILURE 

Occupations  which  give  ordinary  exer- 
cise need  not  be  changed.  A  sedentary 
life  results  in  poor  pulmonary  expansion 
and  defective  digestion.  Rough  manual 
labor  or  work  producing  great  fatigue 
should  be  abandoned. 

Diet,  The  diet  should  be  plain  and 
composed  of  articles  which  are  known  to 
be  easily  digested.  The  meals  should  be 
taken  regularly  and  eating  between 
meals  avoided.  The  weight  should  be 
watched  and  the  diet  regulated  accord- 
ingly. Overweight,  especially  when  due 
to  fat,  throws  more  work  on  the  heart 
muscle.  Moderation  in  all  things  must 
be  the  rule  in  cardiac  disease.  Consti- 
pation should  be  carefully  avoided. 

Drugs.  In  chronic  cardiac  affections, 
digitalis  in  its  various  forms  is  our 
greatest  aid.  In  many  early  cases  it  is 
unnecessary.  When,  in  suitable  cases, 
digitalis  fails  it  may  be  due  to  a  poor 
preparation,  insufficient  dosage  or  a  too 

41 


HARVARD  HEALTH  TALKS 

advanced  stage  of  the  disease.  In  recent 
years  much  effort  has  been  made  to  se- 
cure potent  digitalis  and  the  physician 
should  be  careful  to  obtain  a  reliable 
preparation.  He  must  watch  its  action 
and  regulate  the  amount  accordingly. 
It  acts  by  slowing  and  strengthening  the 
heart.  The  circulation  is  improved  and 
dropsy,  when  present,  relieved.  Several 
years  ago  it  was  discovered  that  quinin 
could  occasionally  abolish  an  absolute 
irregularity  of  the  heart  action,  and  its 
use  in  the  form  of  quinidin  sulphate  has 
added  an  important  drug  to  the  list  of 
cardiac  remedies.  It  cannot  be  used  with 
the  same  ease  as  digitalis  but  only  in 
carefully  selected  cases  under  close  and 
competent  observation.  Since  gross  ir- 
regularity of  the  heart  is  a  common 
sequel  of  several  of  its  diseased  condi- 
tions, it  is  obvious  that  any  drug  which 
will  restore  normal  rhythm  is  of  great 
value.  It  is  necessary,  however,  that 
further  study  should  be  given  by  physi- 

42 


CAUSES  OF  HEART  FAILURE 

cians  before  the  drug  passes  into  com- 
mon use,  and  it  is  quite  possible  that  this 
stage  will  never  be  reached,  but  will  be 
limited  to  certain  cases  which  the  cardi- 
ologist considers  favorable.  The  various 
hypnotics  are  useful  as  already  stated, 
and  morphia  is  of  great  help  to  the 
chronic  cardiac  patient  with  marked 
failure  of  the  heart  muscle. 

In  the  anginal  type  of  heart  disease 
nitroglycerin  and  sodium  nitrite  are  valu- 
able agents.  Pearls  of  amyl  nitrite  should 
be  carried  by  the  patient  to  relieve  an 
attack  of  angina  pectoris. 

The  patient  with  any  form  of  recog- 
nized heart  disease  should  not  attempt 
to  regulate  the  management  of  his  case, 
but  should  consult  his  physician  at  regu- 
lar intervals.  The  appearance  of  any 
symptom  which  he  does  not  under- 
stand should  be  the  signal  for  medical 
advice. 

In  conclusion  let  me  emphasize  the 
following  points:  > 

48 


HARVARD  HEALTH  TALKS 

1.  Since  disease  is  best  managed  in  its 
incipiency,  the  value  of  routine  physi- 

.  cal  examinations  is  obvious.  Even 
when  the  individual  supposes  that  he 
is  in  perfect  health,  signs  of  disease 
may  be  evident  to  the  physician  and 
the  proper  treatment  instituted. 

2.  Early  recognition  means  early  treat- 
ment in  which  the  proper  manage- 
ment of  the  patient's  mode  of  living 
is  of  more  value  than  drugs.  Further- 
more, the  removal  of  other  diseased 
conditions  will  often  prevent  added 
injury  to  the  heart. 

3.  Many  cases  of  heart  disease  begin  in 
childhood  and  youth  due  to  foci  of 
infection  and  the  early  eradication  of 
these  causes  will  save  many  lives. 
Thorough  protection  against  infec- 
tious diseases  is  very  essential. 

4.  The  public  should  fully  reaUze  the 
important  part  which  venereal  dis- 
ease, especially  syphilis,  plays  in  the 
causation  of  cardiac  disease. 

44 


CAUSES  OF  HEART  FAILURE 

In  the  majority  of  cases  heart  disease 
does  not  cause  sudden  death  but 
means  years  of  inactivity  and  suffer- 
ing. Apart  from  this  the  economic 
waste  is  tremendous. 
The  responsibiHty  for  the  diffusion  of 
knowledge  concerning  the  causes  and 
prevention  of  heart  disease  rests  with 
physicians  and  other  qualified  per- 
sons who  by  individual  instruction 
and  public  lectures  should  awaken 
the  community  to  the  means  of  de- 
creasing unnecessary  suffering  and 
disability. 


45 


PBINTED  AT 

THE  HARVARD  UNIVEBSITT  PRESS 

CAMBRIDGE,  MASS.,  U.  S.  A. 


RETURN     BIOLOGY 
TO— #>     3503 


LIBRARY 

Life  Sciences  BIdg. 


642-253 


LOAN  PERIOD  1 


ALL  BOOKS  MAY  BE  RECALLED  AFTER  7  DAYS 
Renewed  books  ore  subject  to  immediate  recall 

DUE  AS  STAMPED  BELOW 


0y€ — 


Subject  to  Recall 


iDfflediate! 


i  I  1C37 


UNIVERSITY  OF  CALIFORN 
FORM  NO.  DD4,  12m,  12/80        BERKELEY,  CA  9A. . 


;:>4-'. 


y 


UNIVERSITY  OF  CALIFORNIA  LIBRARY 


